“On the 13th March 2023 Miss Adris had a telephone review with , GP at The Park Medical…”

The coroner’s concerns

– 1. On the 13th March 2023 Miss Adris had a telephone review with , GP at The Park Medical Centre, who recorded that she had been taking for 2 weeks, had spoken to the primary mental health worker and had been referred to ‘Our roots’ for therapy and had an appointment. She also recorded: “states nothing seems to be helping her at present, states that she feels like things are worsening daily, states she has very poor concertation-cant watch TV and having to walk out at work as cant concentrate...she has a history of severe mental illness-with her being under HTT and sectioned in 2019. Patient states she isnt as bad as she was then but her mood is getting worse. States she wants to go to sleep and not wake up asked if she has suicidal thoughts-states she has but wouldn't act on it right now-asked why states couldn't do it to her family. Advised therefore for referral to psychiatry.” 2. explained in her evidence that although she knew that Miss. Adris had seen the primary mental health team nurse, , on the 8th March and had th another appointment arranged for the 30 March, she specifically wanted to make the referral to the community mental health team so that the opinion of a psychiatrist could be obtained if necessary. She said she felt this was warranted because of Miss. Adris’s history that she was getting worse daily and now couldn’t concentrate alongside her significant history. She filled out a BSMHT form entitled ‘Referral form for access to secondary mental health services’ which contained the record of the review and selected from the urgency options ‘Within 1 to 4 weeks of referral for all other referrals that do not fit within the above two categories [for assessment within 24 hours or symptoms of psychosis], but who require assessment and treatment by secondary mental health services.’ On the electronic submission she marked the referral as ‘urgent’ as the only options are ‘urgent’ or ‘routine’ and she didn’t feel this was routine. 3. That referral was received by the single point of access (‘SPOA’) but as Miss. Adris was under the care of the primary mental health team/neighbourhood team it was not sent to the community mental health team (‘CMHT’) but sent back to Mr. Agyepong at the primary , Clinical Services Nurse mental health team. A statement from Manager, Little Bromwich Centre, provided evidence that this is the system in operation for patients on the case list of the primary/neihbourhood mental health team. reviewed the referral on the 14th March and decided there was no need to bring Miss. Adris’s appointment forward or refer her to the CMHT as her thoughts were not active and there didn’t appear to him to have been a significant change. 4. said she and her colleagues at the practice were not aware that the referral would not be viewed by the CMHT (she also suspected this was the case for other GPs) and if she had known this she would have called up the CMHT directly because she specifically wanted a psychiatrist’s input. She said that if she’d wanted a further opinion from she would have contacted him directly. In essence she wanted a second opinion from the secondary care team. She also explained that if she had been made aware that the referral had been sent back to the primary mental health team and no action was being taken she would have contacted the CMHT directly to raise her concerns but she wasn’t informed of the outcome of the referral before Miss. Adris’s death. was aware that had seen the referral and was keeping his th appointment on the 30 as he had made a record in the surgery’s records but she didn’t realise this was the end of the referral which she presumed would still be being dealt with by the CMHT. 5. When a GP has referred a patient for review and assessment by secondary services I am concerned that it is not safe that there is no consideration of that referral by secondary services and the GP’s opinion that secondary services need to be involved is unilaterally over-ruled. 6. I am equally concerned that not all GPs are aware that their referral to secondary services will not necessarily be considered by secondary services and that the GP making the referral was not informed that it had, in effect, been rejected. 7. If there are grounds for a GP to believe review and assessment is necessary by secondary services, it creates a risk to life if that review does not take place. Whilst the evidence gives no reason to doubt the expertise and competence of primary care mental health practitioners the fact that they are not caring for patients with conditions requiring management by psychiatrists means that they will not have the same familiarity with such conditions and when psychiatrist input is required. In this case it was my conclusion that on the 14th March the primary mental health practitioner did underestimate the significance of the report of daily deterioration and a new difficulty concentrating for a patient with a history of serious mental illness that had required detention for treatment.

An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.

Source

judiciary.uk, Prevention of Future Deaths reports, 2023-0433

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8 Oct 2026

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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0